[ONLY THE HEALTH-CARE RELATED PORTIONS OF THE FOLLOWING ITEM ARE PRESENTED HERE. -- Steve Freedkin , LIST.HEALTHPLAN Manager] THE WHITE HOUSE Office of the Press Secretary (Nashua, New Hampshire) ______________________________________________________________ For Immediate Release March 15, 1994 REMARKS BY THE PRESIDENT IN TOWN HALL MEETING Elm Street Junior High School Nashua, New Hampshire 9:55 A.M. EST THE PRESIDENT: [...] Finally, we are determined that this will be the year when finally America will join the ranks of other advanced nations to provide comprehensive health care to all of our citizens. (Applause.) Thank you. There is one of your citizens here in New Hampshire to whom we owe a special debt of gratitude, and I want to acknowledge him today, and that's Dr. Everett Koop, who was, as all of you know, Surgeon General under President Reagan and who lives here in New Hampshire, and who works here and has been of enormous help to the First Lady in the work they have done conducting forums throughout the country, trying to get doctors and nurses and medical centers involved in developing this health care plan and making sure it will work. He has played a major role in that, and I am very grateful to him for that. (Applause.) You may have seen in the press reports, my wife was out in Colorado yesterday and had huge crowds of students at Boulder, with big signs saying, "Give 'em health, Hillary." (Applause.) Make no mistake about it, some of the people who are giving me hell in Washington are doing it so I can't give you health. But I'm going to try to give you health and take whatever it is they want to give me in return for making sure you get what it is you're entitled to. (Applause.) Now, I'm anxious to answer your questions. But let me just make a point or two about this. New Hampshire has a lot of strengths in terms of the health care you already have that many other states don't. And so you may say, well, what's in this for us? You have, for example -- only about five or 10 percent of your people don't have access, physical access to good medical care. Most states, as rural as New Hampshire have a far higher percentage of people who don't even have access. You have one of the finest immunization programs in the country. You've already done a lot of what the rest of the country needs to do in community-based mental health services. There are a lot of things that you can be very proud of. You have a higher percentage of your people who are insured and, therefore, a lower percentage of your people who are uninsured. So you say, well, what do we get out of this? First, there will be no more uncompensated care, so the people who are providing health care will have some reimbursement because everybody will have insurance. Second, the people who are covered by Medicare but aren't poor enough to be on Medicaid - -- the kind of people I met at the Moe Arel Center -- will, for the first time, have access to prescription medicine. (Applause.) And we'll phase in support for long-term care over and above and in addition to nursing home, so that there will be some support for in-home care or community-based care. This is very important. The fastest growing group of Americans are people over 80. And more and more people over 80 are quite vigorous and quite able to live good and full lives, but may need some support. Over the long run, if you look at the population trends in this country -- where we are going with our age groups -- over the long run, we will save money if we provide a broader range of long-term care support and enable people to be as independent and as strong as they can for as long as possible. You will benefit from that. The other thing I think is terribly important -- I had a wrenching encounter at the hotel this morning, just before I left to come over here, where a woman came up to me with tears in her eyes, just crying, and she said, my husband just lost his job and we have preexisting medical conditions in our family, and I do not know how we are going to get insurance. Even if you have insurance today, the only people who know they can't lose their insurance are people who work for employers that aren't going out of business and aren't ever going to lay anybody off. Everybody else is at some risk of losing their insurance, until you get old enough to get on the Medicare program. And that is a serious problem, because we have -- I don't know how many people I've met in this state -- we've got millions of Americans who have someone in their family who's been sick before and have a preexisting condition and, therefore, either can't change jobs for fear of losing their health insurance, can't get insurance now because they've fallen through the cracks, or pay higher rates. So even here in New Hampshire, I assure you, there is something to be gained from having a system in which everyone always has some basic health insurance. We are going to work very hard to make sure we don't mess up what you're doing right here, and give the states the flexibility they need. (Applause.) But we still deal with the fact that we have not solved this problem as a country. And I can tell you that we will never get the deficit erased, we will never balance the budget and we will not restore long-term health to this economy or security to our people until we face this problem. [...] Q I wanted to ask what would happen to someone in the health plan that has insurance already, but exhausts it because of preexisting conditions. How will they benefit from your program? THE PRESIDENT: If you have insurance now -- what did you call it -- Q It's exhausted. THE PRESIDENT: It's exhausted? Q Well, mine isn't at the time, but I'm worried about it in the near future. THE PRESIDENT: You're worried about running up against the limits. Q Exactly. THE PRESIDENT: Yes. About three-quarters of all health insurance policies have what are called "lifetime limits," which means if you get real -- maybe there's an aggregate amount of $1 million, let's say, so that you could lose your health insurance under your existing policy, even if it's a good policy, if you get real sick. Now, a lot of insurance companies under the present economic setup feel like they have to do that because they're relatively small companies, they have a relatively small number of people insured, and they just don't think they can afford it. Under our system, we abolish lifetime limits and we end discrimination against people for preexisting conditions, but we don't bankrupt insurance companies writing health insurance, because we also go to something called community rating. I want to level with you about this, because some of you will pay a little more. Basically, young, single workers will pay a little bit more for their health insurance so that older people and families with preexisting conditions aren't discriminated against. But that's very important because you're going to have people in their 50s and 60s changing jobs in this environment. I met a man from Upstate New York the other day who had a job in a defense company for 29 years. He was 59 years old, he changed jobs and went to work for a hospital. So we're going to go to something called "community rating," which means people will be insured in very large pools, and that's how we'll be able to afford to guarantee that you will not come up against your lifetime limits, there will be no lifetime limits without bankrupting the insurance industry; everybody will be insured in great, big pools. It's much fairer. Young, single, healthy people will pay slightly more, but not a great deal more, and it will permit us not to discriminate in rates against older people and people who had an illness in their family. (Applause.) Q I'm a resident of Nashua, New Hampshire. I have a comment and then a question. The comment is -- and I'm 68 years old -- Whitewater is for canoeing and rafting. (Applause.) Shame on those who would detract and distract from the important work you're doing with universal health coverage and jobs. (Applause.) And now my question. (Laughter.) I have a former husband and two sons with major or chronic mental illnesses. I'm a member of the Nashua Alliance for the Mentally Ill. I've been on the board of the New Hampshire Alliance for the Mentally Ill, and I'm a member of the National Alliance for the Mentally Ill. And I would like to join Rosalyn Carter and Betty Ford in asking and urging that we pass Parity for People With Mental Illness in the health bill that you're proposing -- now, not in the year 2001. (Applause.) And, finally, I'm also a volunteer with Nashua's new, one-year-old Neighbor To Neighbor Clinic, which provides health care for those who have no health insurance. We want to go out of business and we need your help. (Applause.) THE PRESIDENT: Bless you. Let me also say that in regard to the mental health comment you made that in addition to Rosalyn Carter and Betty Ford, that position is most strongly urged in our administration by Tipper Gore, who is a real mental health advocate and has done a wonderful job on this issue. (Applause.) Let me explain what the problem is to everybody else. This health care plan basically has a guaranteed set of benefits which means that every plan after this, if you have a plan that gives these benefits or gives more, you won't be affected. If you don't have any insurance, or your insurance doesn't provide some of these benefits, then the benefits would have to be included if the bill passes. The principal new things we do that oftentimes aren't in health care plans are primary and preventive things -- tests like cholesterol tests or mammograms or things like that -- things that we believe save a lot of money over the long run -- primary and preventive care. We also begin to phase in alternatives to nursing home and long-term care, as I said. And we phase in full parity for mental health benefits, as she noted, up to the year 2000. The mental health community says -- and by the way, I think they're probably right -- that you ought to start with full mental health coverage as soon as all other coverage is phased in. You know, if it takes two or three or four years, whenever you put all the other stuff in, put mental health in right then and you will probably save money on it. Now, let me just explain what the problem is, because, in principle, I agree with you. But any bill I pass -- any bill the Congress passes, as Congressman Swett can explain -- has to have a price tag on it that has been certified by the bipartisan, or nonpartisan Congressional Budget Office. They have to say, here's how much the bill will cost, here's how it's going to be paid for, and here's why it won't increase the deficit. That's the laws under which we're operating now. The problem is that under the budget rules, no one knows -- we know how much mental health coverage will cost, but we don't know how much it will save. So, to try to get full parity, we went -- I didn't, the First Lady and her group went to 10 different actuaries to try to get the best possible figures we could get on what mental health coverage would cost. And we couldn't ever get a consensus that the Congressional Budget Office would buy. I'm not trying to paint them as the bad guys, by the way, they're not the bad guys; they just don't know. So what we may have to do is to start off with the mental health benefits phased in, then show what the costs are of the new things we're doing, and if they're lower than they're projected to be, then we can accelerate the time in which the full coverage comes in. That's the only possibility that I see right now because of the budgetary problem we have. And this is a problem, by the way, we face in lots of other areas where we're doing something we know will have a good benefit, but we can't prove it. I'll give you another example so it might be clearer to you. When we passed the North American Free Trade Agreement for trade with Mexico, everybody said it would increase trade with Mexico and jobs in the short run; everybody said that, even the people that weren't for it thought it would increase jobs in the short run. But we had to count it as a net negative for the budget because we had to reduce tariffs which weren't coming in. So we counted all the losses, we could count no estimated gains from increasing sales. So if some company from New Hampshire sells more in Mexico, it earns more money and pays more federal income tax, right? We couldn't count any of the estimated increase in federal income tax; we had to count all the losses. That's what happened in mental health, which is the problem I'm facing. If we can figure out a way around it, we'll try to accelerate the coverage. But it's a budgetary problem. You're absolutely right, it has to be done, but better it be done in 2000 than not at all; and I'll try to figure out how to do it quicker. (Applause.) [...] Q I'm a recovering Republican. (Laughter.) We made you the comeback kid a few years ago, and we hope to send that message from this town meeting to Mr. Dole and his friends in the media -- (applause) -- that we're very focused; the people are very focused. We're concerned with jobs and health care. And my question is very focused on health care. My husband's job just changed to HMOs, and they chose for us the doctors that we would see. I had to leave the doctors in Salem and go to Massachusetts to where the HMO was. In your health care plan, will I have more freedom to choose and maybe go back to my own doctors that I've used -- a specialist I've used for my son, who is disabled and myself than I do now with this HMO? (Applause.) THE PRESIDENT: Yes. The short answer is yes, but let me explain. Let me try to explain. The short answer is yes, but let me try to amplify it a little bit because I don't want to be misleading in any way. If we do nothing, if we walk away one more time from this health care crisis, what's going to happen is more and more employers will turn to HMOs because they have to to pay their medical bills because the cost of medical care has gone up two and three times the rate of inflation. Many of these HMOs will do an excellent job and will be widely supported and be well and warmly received. Some of them will be not so well received because people either won't want to give up their personal physicians, or especially if they've had -- you mentioned you had a son with a special problem -- if they've had someone that required special treatment, they'll have a particular anxiety about that. Now, if our plan were to pass as it is today, here is how your situation would be different. Your employer could choose to do work with the HMO and could point out that the HMO would provide all the services required in the health care plan, and could even provide a discount for it -- that is, could give you a financial incentive to do it. Under our plan, every year you would be given at least three choices -- at least three choices: this HMO, some other plan -- let's say a PPO, a group of doctors get together and offer their services, and maybe would let any other doctor, including your doctor, sign on if he would agree to give the services at the same price; and then strict fee-for-service medicine, the situation you have now. You might have to pay a little more, but your employer would still have to make a contribution. So you would have those choices. In addition to that, we are trying to set up in our plan the situation where, if someone has a specialist like you do for a special problem, if the specialist will provide the service for the same price that the HMO specialist will provide it, then the specialist should be able to provide that even if you go to the HMO. So you could maybe do the -- (applause) -- so you could maybe get a compromise. We're working on that. But I don't want to kid you. The employer would still have the option to pick an HMO and that would still be a less expensive option that the fee-for-service. But you would be able to get the fee-for-service and your employer would have to make the same contribution to that plan as he or she would to the HMO. So you would have much more choice than you have now. Right now -- I think it's important that everybody understand this -- right now, most people who have insurance are insured in the workplace, and only about half, actually slightly fewer than half have any real choice of providers today who are insured through the workplace. So the amount of choice is going down. Now, as I said, there are some very, very good HMOs. New England has some very good HMOs that have done a terrific job. But a lot of people want to have the choices. Under our plan, we will promote and facilitate the growth of good HMOs because there will be economic incentives for people to compete for lower cost but higher quality medicine. But we will protect the choices people have, which are vanishing at a very rapid rate today. And we'll try to work out the -- we're really trying to work out the specialist problem, because that's the thing people are most traumatized about. Someone has been taking care of a family member with a special problem and have to give it up -- it's really tough on them. Q I come from a town called Amherst, where I'm a distinct minority -- I'm a Democrat. (Laughter.) And my husband and I have just become editors of a small news letter, and we sent you a copy to the White House, as a matter of fact. I'm concerned about health care because I'm one of those people with lots of preexisting conditions and my husband is a contract engineer, and insurance doesn't come with his job. I'm afraid when I hear news reports of you having to compromise to get this bill through Congress. I'm afraid that one of the things you may have to compromise on is people like me. Is that so? THE PRESIDENT: No, there will be no compromise on everybody being covered. There's no point in doing it if we're not going to cover everybody. (Applause.) There is no point in doing it if we're not going to cover everybody. But what I want you to understand -- I want every one of you to understand that there are consequences to all human behavior, including inaction. We all know that, but sometimes we forget it. If we do not act, certain things will happen. Some of you will go into HMOs and you'll be very well satisfied and you'll get good health care at lower costs. Some of you will go into HMOs and you'll lose your choices of doctors, and you'll feel that quality has suffered and you'll be frustrated and angry. Some of you will lose health coverage because every year we lose about 100,000 people a month in the United States who lose their health insurance permanently. And every year, at some point during the year, there are over 50 million of us who don't have any health insurance. So what I want you to understand is I won't pretend to have all the answers; I don't pretend that we're right about everything. This is a complicated subject. But there are consequences to every course of action, including doing nothing. And they are quite significant, the consequences of doing nothing. It also means, to go back to the lady over there, it means no mental health coverage; it means no medicine for people on Medicare but not on Medicaid; it means no medicine for working families who have health plans that don't cover medicine now, may have kids with high medicine costs. So the one thing we have to do is to find a way to cover everyone, which means you can't lose your coverage because you have preexisting conditions. And in my judgment, it means that people who work for small businesses or who are self- employed should have access to insurance at more or less the same rates that those of us who work for government or big companies do. I don't think people who have access to the federal plan, which is terrific, by the way -- it's a cafeteria plan. Any of you are federal employees, you know that. I mean, we've been able to manage our costs. Some of our plans have even gone down in price this year. We have all these choices. I don't think people who work for the federal government who don't know anybody else or talk to them can possibly imagine the level of insecurity that grips people that don't have this level of certainty. That may be one of our problems now in Washington. But the answer to your question is, if we're not going to cover everybody -- if we can't find a way to find universal coverage, there is no point in doing this. That's what I said in my State of the Union speech. I'm very flexible -- a lot of people have good ideas. A lot of people have better ideas, perhaps, than I do on certain things. We may have to be flexible to pass a plan around the edges. But we have to provide coverage for everybody. Otherwise we haven't done what we set out to do. (Applause.) [...] The Congressional Budget Office, even though they disagreed with our cost figures in the first three years, say that, 10 years from now, our health care plan will be saving the Treasury $150 billion a year -- a year. So you're absolutely right -- if we don't do something else, we can't keep the deficit coming down. I think the next something else should be the health care. (Applause.) [...] THE PRESIDENT: Bless you. Thank you all very much. We've got to quit. Thank you. (Applause.) END 10:49 A.M. EST